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EXPRESS BUILDING PERMIT APPLICATION C E ! V E D
TOWN OF YARMOUTH _W__
Yarmouth Building Department OCT 3 0 2019
1146 Route 28 ,
South Yarmouth, MA 02664 a ui E3-IT
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 2 \ lI`^t LaK ;`� \�" ��i
ASSESSOR'S INFORMATION: , /
Map: Parcel:
OWNER: Dc.r1Y�.... // (1--i cl91 - \ ?- 3ut2 A/
NAME .,Mike McCarthy [Iiottat n•: TEL. #
CONTRACTOR: ;,, PO Box 52
NAME West Dennis, IVIA AVAsS TEL.#
�/ Cell 508) 280-6964
®'Residential Lm 8a33 HIC-169393 Est.Cost of Construction$ 'yct'
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation 7
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: .4. J e.'Xc.
Location of Facility
I declare under penalties of perjury that th emen he in contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial or revocati li prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: L Date: 1°I3. II‘
hI 4
Owners Signature(or attachment) LL/_J�(�_ Date:
Approved By: ri G Date: /'----.
Building Official d • ee) EMAIL 1tESS:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
3B1 302y
Permit Authorization
mass save Form '-t 0 s,,`( e.- 13
Samosas through energy Ffhuency
Site ID: 3864665 Customer: Donna Mudie
I, O r i ii 4 i1 u d;e ,owner of the property located at:
(Owner's Name,printed)
21 Flintlock Way Yarmouthport, MA 02675
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
Owner's Signature: Of0"\AAA.,e"...,
Date: 9 - u'
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: RISE Engineering
Phone: 401-784-3700
Email:
Page 1 of 1 For Office Use Only
Rev.102015
„F"-4 F0/74/2-4617-4ted10-/ ee4e/€4_
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
-- '
Type: Individual
Registration: 169393
. - • , ...
MICHAEL MCCARTHY Expiration: 06/15/2021
P.O.BOX 52 •,
- ,
WEST DENNIS,MA 02670
Update Address and Return Card.
SCA 1 CP 20M-05/17
.01,:e Wevrirraeweieczaile>/://gaJJacife&sel4
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:Individual before the expiration date. If found return to:
iRegistration Exoiration Office of Consumer Affairs and Business Regulation
1-69392 ----_- 06/15/2021 1000 Washington Street -Suite 710
MICHAEL MCCARTHY Boston,MA 021184 • I --
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MICHAEL F.MCCARTHY,: /2 / i• /: i // /
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6 RANGLEY LN. • : 1' - 1,4,,x,afa i aties4
..:,SOUTH DENNIS,MA-02660 Undersecretary i. Not vaiktAiiithout signature
ii"-"6"-1 Board Of PrpfelialtaRegatifitclafluil:ntssi aLacitndh:settslrattide ards
- ., .•.• -
. MMus'McCarthy 1 ,_•
ConstrIjontitiviprvi
sor Pileftriby Comptmotton CS=058633 --
' Has succtioletsity COMpietict the-14100ml Fair• •'--1-•.' '4,ireS;04/1941419
Cellulose Tailning Mum ,
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. MICHAEL
..'. te diyeAtigurit WM ,
17.
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/Of • PO Box 62 -_,-_,,
WEST DENNtrAtA
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COMMISSiedter .cet At-- •
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OSHA 001558.712
U.S.Oepartment of _
"*"glatfNllrnt,g411W*ieCttirUilhsR
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Labor ,
OncdP0SdnaSalang and Health Adminisdadcin
Michael McCarthy
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hailu.cquiffAyomptosa,t104140r0c,p!roPROISaffplOndmengia •':. : . ..,•. - ::':,-. .- . 4410** :...0tety :,:..•..: ,r.'. ,.. .Takiliv:00U6104.--, - •- ' , - - priaituittlissiTim. ' '''''. :”.
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• - The Commonwealth of Massachusetts
w_=
►�=41-.= '/ Department of Industrial Accidents
•• E =W.gill= 1 Congress Street,Suite 100
c11 , • Boston,MA 02114-2017
•
•
www.massgov/alit
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
• TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information *� ���/� Please Print Legibly
Name{Business/Organization/Individual): M l SlcCarthy .
Address: PO Box 52
- - City/State/Zip: -- ------- West �1Rlb — _- -------
one
•
Are you an employer?Check the appropriate box: Type of project(required):
1.�I am a employer with � employees(full and/or part-time).* 7. New construction
2.0 I am d Sole proprietor of partnership and have no employees working for me in 8. Ei Remodeling
any capacity.[No workers'comp.insurance required.). •
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 0 Building addition
• • ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am.a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
• 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[ ther 1'r �•I+
152,11(4),and we have no employees.[No workers'comp.insurance required.] •
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andJob site
information.
•
Insurance Company Name: �'Ft'c,n�I Li c,>,1 i 4-/ 4- 1i ft s
Policy#or Self-ins.Lic.#: V 1 k/C-7-`I 3 sly Expiration Date: P-•
1►f11
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable.by•a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify and t e ins - 'enalties of perjury that the information provided above is true and correct.
Signature: Date: I I'fl t F
• Phone#: 2-j0-G IC c,
Official use only. Do not write in this area,to le completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one): •
1.Board of Health 2.Building Departmeht 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: